Risk Adjustment In Neurocritical care (RAIN)--prospective validation of risk prediction models for adult patients with acute traumatic brain injury to use to evaluate the optimum location and comparative costs of neurocritical care: a cohort study.

OBJECTIVES: To validate risk prediction models for acute traumatic brain injury (TBI) and to use the best model to evaluate the optimum location and comparative costs of neurocritical care in the NHS. DESIGN: Cohort study. SETTING: Sixty-seven adult critical care units. PARTICIPANTS: Adult patients admitted to critical care following actual/suspected TBI with a Glasgow Coma Scale (GCS) score of < 15. INTERVENTIONS: Critical care delivered in a dedicated neurocritical care unit, a combined neuro/general critical care unit within a neuroscience centre or a general critical care unit outside a neuroscience centre. MAIN OUTCOME MEASURES: Mortality, Glasgow Outcome Scale - Extended (GOSE) questionnaire and European Quality of Life-5 Dimensions, 3-level version (EQ-5D-3L) questionnaire at 6 months following TBI. RESULTS: The final Risk Adjustment In Neurocritical care (RAIN) study data set contained 3626 admissions. After exclusions, 3210 patients with acute TBI were included. Overall follow-up rate at 6 months was 81%. Of 3210 patients, 101 (3.1%) had no GCS score recorded and 134 (4.2%) had a last pre-sedation GCS score of 15, resulting in 2975 patients for analysis. The most common causes of TBI were road traffic accidents (RTAs) (33%), falls (47%) and assault (12%). Patients were predominantly young (mean age 45 years overall) and male (76% overall). Six-month mortality was 22% for RTAs, 32% for falls and 17% for assault. Of survivors at 6 months with a known GOSE category, 44% had severe disability, 30% moderate disability and 26% made a good recovery. Overall, 61% of patients with known outcome had an unfavourable outcome (death or severe disability) at 6 months. Between 35% and 70% of survivors reported problems across the five domains of the EQ-5D-3L. Of the 10 risk models selected for validation, the best discrimination overall was from the International Mission for Prognosis and Analysis of Clinical Trials in TBI Lab model (IMPACT) (c-index 0.779 for mortality, 0.713 for unfavourable outcome). The model was well calibrated for 6-month mortality but substantially underpredicted the risk of unfavourable outcome at 6 months. Baseline patient characteristics were similar between dedicated neurocritical care units and combined neuro/general critical care units. In lifetime cost-effectiveness analysis, dedicated neurocritical care units had higher mean lifetime quality-adjusted life-years (QALYs) at small additional mean costs with an incremental cost-effectiveness ratio (ICER) of £14,000 per QALY and incremental net monetary benefit (INB) of £17,000. The cost-effectiveness acceptability curve suggested that the probability that dedicated compared with combined neurocritical care units are cost-effective is around 60%. There were substantial differences in case mix between the 'early' (within 18 hours of presentation) and 'no or late' (after 24 hours) transfer groups. After adjustment, the 'early' transfer group reported higher lifetime QALYs at an additional cost with an ICER of £11,000 and INB of £17,000. CONCLUSIONS: The risk models demonstrated sufficient statistical performance to support their use in research but fell below the level required to guide individual patient decision-making. The results suggest that management in a dedicated neurocritical care unit may be cost-effective compared with a combined neuro/general critical care unit (although there is considerable statistical uncertainty) and support current recommendations that all patients with severe TBI would benefit from transfer to a neurosciences centre, regardless of the need for surgery. We recommend further research to improve risk prediction models; consider alternative approaches for handling unobserved confounding; better understand long-term outcomes and alternative pathways of care; and explore equity of access to postcritical care support for patients following acute TBI. FUNDING: The National Institute for Health Research Health Technology Assessment programme

Repeated downsweep vocalizations of the Araguaian river dolphin, Inia araguaiaensis

Funding was provided by the Swarosvki Foundation and World Wide Fund for Nature Brazil.Araguaian botos (Inia araguaiaensis) are known to produce pulsed as well as tonal sounds. This study documents the first evidence for repetitive sequences of downsweep whistles in botos that appear to be shared between individuals, and the context of their occurrence is investigated. Boat surveys were conducted along the Tocantins River located in the Eastern Amazon over a period of 42 days between 2012 and 2018. Eighty-two groups of Araguaian botos were observed, and 43 h of sound recordings were acquired. 632 downsweep whistles were recorded in 10 encounters. Four of these encounters contained downsweep bouts (21 bouts with ≥2 whistles) with short inter-call intervals (bout criterion 50 s) and up to 161 whistles. A statistical relationship was not found between downsweep occurrence and any of the contextual parameters that were investigated, including socializing, travelling, feeding, group size, presence of calves, and socio-sexual displays. The rarity of these signals makes them unlikely candidates for individual or group identification. It is more likely that they are associated with very specific contexts, such as nursing or mating, both of which were rarely observed in this study. Further studies are required to investigate context specificity and elucidate the function of these signals.PostprintPeer reviewe

Evidence for internal field in graphite: A conduction electron spin resonance study

We report conduction electron spin resonance measurements performed on highly oriented pyrolitic graphite samples between 10 K and 300 K using S (f = 4 GHz), X (f = 9.4 GHz), and Q (f = 34.4 GHz) microwave bands for the external dc-magnetic field applied parallel (H || c) and perpendicular (H perp c) to the sample hexagonal c-axis. The results obtained in the H || c geometry are interpreted in terms of the presence of an effective internal ferromagnetic-like field Heff-int(T,H) that increases as the temperature decreases and the applied dc-magnetic field increases. We associate the occurrence of the Heff-int(T,H) with the field-induced metal-insulator transition in graphite and discuss its origin in the light of relevant theoretical models.Comment: 10 pages (tex), 5 figures (ps

Anomalous critical fields in quantum critical superconductors.

Fluctuations around an antiferromagnetic quantum critical point (QCP) are believed to lead to unconventional superconductivity and in some cases to high-temperature superconductivity. However, the exact mechanism by which this occurs remains poorly understood. The iron-pnictide superconductor BaFe2(As(1-x)P(x))2 is perhaps the clearest example to date of a high-temperature quantum critical superconductor, and so it is a particularly suitable system to study how the quantum critical fluctuations affect the superconducting state. Here we show that the proximity of the QCP yields unexpected anomalies in the superconducting critical fields. We find that both the lower and upper critical fields do not follow the behaviour, predicted by conventional theory, resulting from the observed mass enhancement near the QCP. Our results imply that the energy of superconducting vortices is enhanced, possibly due to a microscopic mixing of antiferromagnetism and superconductivity, suggesting that a highly unusual vortex state is realized in quantum critical superconductors.We thank Igor Mazin and Georg Knebel for useful discussions, and A. M. Adamska for experimental help. This work was supported by the Engineering and Physical Sciences Research Council (Grant No. EP/H025855/1), EuroMagNET II under the EU Contract No. 228043, National Physical Laboratory Strategic Research Programme, and KAKENHI from JSPS.This is the final published version. It first appeared at http://www.nature.com/ncomms/2014/141205/ncomms6679/full/ncomms6679.html

Online videos: The hidden curriculum

Introduction: Dental undergraduates will access the Internet searching for learning materials to complement their training; however, open access content is not generally recommended by dental schools. This study aimed to evaluate how dental students are using online video content. Materials and Methods: Students from eight Universities (Athens, Birmingham, Brescia, Cardiff, Melbourne, Paris, Sao Paulo and Valdivia) representing three continents were invited to complete a survey on their access and learning from online videos. Results: International students behave similarly when studying dental content online. Of 515 respondents, 94.6% use the Internet as a learning tool. It was observed that videos are not frequently recommended during didactic lectures (9.6%). But many students (79.9%) will use YouTube for their learning which includes clinical procedures. Students will check online content before performing procedures for the first time (74.8%), to understand what was explained in class (65.9%) or read in books (59.5%), to relearn clinical techniques (64.7%) and to visualise rare procedures (49.8%). More than half of the students do not fully trust the accuracy or the reliability of online content. This does not prevent students from watching and sharing dental videos with classmates (64.4%). The content watched is not shared with teachers (23.3%) even when it contradicts what was learnt in the school (38.2%). Conclusion: This study concludes that students regularly integrate open access digital resources into learning portfolios but are hesitant to inform their teachers about their viewing habits. Students wish to receive critical skills on how to evaluate the material they encounter outside their traditional learning space

Tree method for quantum vortex dynamics

We present a numerical method to compute the evolution of vortex filaments in superfluid helium. The method is based on a tree algorithm which considerably speeds up the calculation of Biot-Savart integrals. We show that the computational cost scales as Nlog{(N) rather than N squared, where $N$ is the number of discretization points. We test the method and its properties for a variety of vortex configurations, ranging from simple vortex rings to a counterflow vortex tangle, and compare results against the Local Induction Approximation and the exact Biot-Savart law.Comment: 12 pages, 10 figure

Effective Caspase Inhibition Blocks Neutrophil Apoptosis and Reveals Mcl-1 as Both a Regulator and a Target of Neutrophil Caspase Activation

Human tissue inflammation is terminated, at least in part, by the death of inflammatory neutrophils by apoptosis. The regulation of this process is therefore key to understanding and manipulating inflammation resolution. Previous data have suggested that the short-lived pro-survival Bcl-2 family protein, Mcl-1, is instrumental in determining neutrophil lifespan. However, Mcl-1 can be cleaved following caspase activity, and the possibility therefore remains that the observed fall in Mcl-1 levels is due to caspase activity downstream of caspase activation, rather than being a key event initiating apoptosis in human neutrophils

Perspective from a Younger Generation -- The Astro-Spectroscopy of Gisbert Winnewisser

Gisbert Winnewisser's astronomical career was practically coextensive with the whole development of molecular radio astronomy. Here I would like to pick out a few of his many contributions, which I, personally, find particularly interesting and put them in the context of newer results.Comment: 14 pages. (Co)authored by members of the MPIfR (Sub)millimeter Astronomy Group. To appear in the Proceedings of the 4th Cologne-Bonn-Zermatt-Symposium "The Dense Interstellar Medium in Galaxies" eds. S. Pfalzner, C. Kramer, C. Straubmeier, & A. Heithausen (Springer: Berlin